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Harding, C. (2009).

An evaluation of the benefits of non-nutritive sucking for premature infants as


described in the literature. ARCHIVES OF DISEASE IN CHILDHOOD, 94(8), pp. 636-640. doi:
10.1136/adc.2008.144204

City Research Online

Original citation: Harding, C. (2009). An evaluation of the benefits of non-nutritive sucking for
premature infants as described in the literature. ARCHIVES OF DISEASE IN CHILDHOOD, 94(8),
pp. 636-640. doi: 10.1136/adc.2008.144204

Permanent City Research Online URL: http://openaccess.city.ac.uk/3572/

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An evaluation of the benefits of non-nutritive sucking


for premature infants as described in the literature
ADC

C Harding
ABSTRACT
Babies have specific needs that assist them in their
development and enable them to thrive. Feeding is an
important aspect of development. When feeding, there
are opportunities for babies to develop a positive
interactive bond with parents. This has a long-term
impact on the well-being of infants in terms of emotional
development, social learning, and health. Infants born
prematurely and those born with specific needs making
them vulnerable are likely to develop the necessary skills
to allow them to mature, interact and thrive.
Many premature infants may need alternative feeding
methods until they are ready to develop the skills
necessary for oral feeding. A beneficial approach for
infants who are showing oral readiness is the use of a
non-nutritive sucking programme. This paper explores the
research that supports non-nutritive sucking, and considers
other variables that need to be included in further
research, including those infants who have neurodisability.

What is already known on this topic


c Non-nutritive sucking is a beneficial process in
helping to stabilise the infant during a range of
processes.
c In particular, non-nutritive sucking has been
shown to assist quicker transition from tube- to
oral feeding within a premature infant
population.
What this study adds
c Consideration about how future studies need to
consider the benefits of non-nutritive sucking
and its application to a neurodisability population
of premature infants.
c Evaluation of current research in relation to
current practice and how it can be applied to the neonatal environment.
Feeding is an essential early routine that is
necessary for nutrition and for developing a
positive bond between parents and infants. It
therefore has a long-term impact on the consolidation
of well-being.1 As well as being a social
activity, feeding involves the use of tactile and
olfactory senses that are essential in an infants
early development. Management of these skills in a
vulnerable infant population requires a sensitive,
multidisciplinary approach to maximise each
infants potential.2 This short report seeks to
explore the use of non-nutritive sucking as a
support for premature infants in the development
towards a smooth transition towards oral feeding.
It will also consider the relevance of the evidence
base for effective clinical application. A pilot
project will be discussed that seeks to explore
some of these issues.

SUCKING BEHAVIOUR IN INFANTS


Sucking in particular is vital in the early development
of the infant whether it involves breast- or
bottle feeding. It is essential as the means of
receiving nutrition, of providing stability in distress
and also of exploring the environment. Successful

and effective feeding is an energetic activity that is


described as being complex, requiring the coordination
of a suckswallowbreathe cycle.3 4 Research
studies show that a stable swallow rhythm appears
to be established earlier than a suck rhythm.5 In the
high-risk neonatal population, the suckswallow
breathe sequence is rarely well coordinated before
34 weeks.5 Premature infants often require approximately
20 postnatal days to achieve a maximal suck
rate and their suckswallow patterns are immature, displaying a dysrythmic pattern, although individual
variation is recognised within this population.6
Infants use two types of sucking. Nutritive
sucking is the process of obtaining nutrition with
a rate of one suck per second, and is constant over
the course of feeding. It involves intake of fluid due
to the alternation of expression and suction.
Suction is the negative intraoral pressure which
occurs when the tongue and jaw become lower and
the soft palate closes the nasopharynx.7 8 In
contrast, non-nutritive sucking occurs at two sucks
per second, in the absence of nutrient flow and
may be used to satisfy an infants basic sucking
urge or as a state regulatory mechanism.8 9 The two
forms also differ in their influence on respiratory
rate. Paludetto et al10 and Daniels et al9 suggest that
increases in transcutaneous oxygen levels occur
during non-nutritive sucking. They suggest that
there is a higher respiratory rate during nutritive
sucking pauses whereas in non-nutritive sucking,
the respiration occurs during the sucking. Key
environmental factors also influence the feeding
process. They are the presence/absence of fluid,
their viscosity11 and satiation, that is, the presence
of milk in the stomach which inhibits nutritive
sucking.12

THE NEONATAL ENVIRONMENT


The hospital neonatal environment is specifically
designed to provide support and to maximise an
infants potential in all areas of development. Most neonatal units will have a developmental care approach to
managing their infants. Such approaches are important in
providing appropriate and supportive environments for infants
and their carers. The family is at the centre of this approach,
and the rationale behind developmental care is rooted in a range
of theories: transactional theory, neurobiological theory, psychoanalytical
theory and synactive theory.13
The Newborn Individualized Developmental Care and
Assessment Program (NIDCAP)13 focuses on observing and
interpreting infant behaviour to allow practitioners and carers
to interpret the infants needs. Individualised care plans
recognise the unique and individual needs of each infant.
Swaddling is a strategy used to reduce stress, and lighting as
well as noise are reduced to a minimum as too much sensory
stimulation can be detrimental to the infants well-being.
Holding the infant, such as in Kangaroo Care can decrease
stress and have positive psychological and emotional aspects. 13 14
The development of feeding for the infant within a
developmental care model is based around observing the infants
general state, then interpreting their behaviour when preparing
them to accept oral intake through approaches such as nonnutritive
sucking. Observations during gavage feeding when the
non-nutritive sucking programme may occur can provide
important assessment information as to how to proceed with
a feeding management plan.13

USING NON-NUTRITIVE SUCKING TO DEVELOP FEEDING SKILLS


Speech and language therapists in collaboration with parents,
carers and other healthcare practitioners often recommend nonnutritive
sucking programmes for tube fed preterm infants. This

is so that the transition to oral feeding is increased, and to


provide a pattern for nutritive sucking. It is considered that nonnutritive
sucking will assist neurodevelopmental organisation,
aid neurobehavioural maturation and optimise ventilation in
preterm babies who require nasal non-invasive ventilatory
support.6 1523 In addition, use of a non-nutritive sucking
programme may allow critical aspects of oral motor development
to receive stimulation and reduce the adverse impact of
other necessary procedures such as nasogastric feeding.24 These
are important considerations as studies show that feeding
difficulties within the neonatal population may prolong
discharge home.25 26 Delayed introduction to oral stimulation
and feeding may also lead to longer-term aversions.2
Breast feeding is regarded as an important method of feeding
for all infants. Its benefits are multi-factorial and include
positive growth and development,27 as well as providing
protection from environmental pathogens28 29 and positive
outcomes for the immune system of a baby.30 Mothers also
report that when breast feeding, they actually feel that they are
promoting a beneficial support for their baby.31 Breast feeding
has many benefits for the developing infant, and the World
Health Organization promotes breast feeding worldwide due to
the many health advantages. However, it can prove particularly
difficult for premature infants and this has posed something of a
challenge for nurses and speech and language therapists who
play a specific role in promoting breast feeding in young infants.
Nevertheless, the speech and language therapists principle
role is to maximise an infants functional sucking skills
regardless of the mothers choice of feeding. Cultural, personal
and health issues may also contribute to the decision as to
whether to breast feed. Concerns have been raised on the use of
dummies and teats during breast feeding. However, there is
little evidence that the inter-changeable use of teats and nipple
presentations causes confusion or that dummy use influences
breast feeding development.32
Healthcare professionals working with neonates have also
used assessments such as the Neonatal Oral Motor Assessment
Scale (NOMAS33), to categorise the oral motor patterns that
underlie poor feeding behaviour in neonates. The NOMAS has
largely been used with bottle fed infants. Meier34 has raised
issues around describing sucking during breast feeding and
suggests that the terminology used in the NOMAS such as
transitional sucking does not translate to breast feeders as a
wide jaw excursion is essential for effective breast feeding.
However, given the Collins et al32 findings above where there is
minimal evidence to support the issue of nipple/teat confusion,
the NOMAS is regarded as a valuable clinical tool. Furthermore,
evaluations have revealed that the NOMAS has a high inter-rater
reliability, and also has been described as being helpful in
identification of those infants who present with long-termrisk.3335

RESEARCH INTO NON-NUTRITIVE SUCKING


Studies have evaluated the impact of non-nutritive sucking on
oral feeding. However, none have clearly addressed the link
between non-nutritive sucking and nutritive sucking, nor have
they proposed an intervention strategy for use in a neonatal
environment. Measel and Anderson6 randomly assigned infants
aged 2834 weeks gestation to a treatment group (use of
dummy during non-oral feeding to provide an association
between sucking and satiation) or control group (no dummy).
Specific details of the treatment protocol are not given, but the
treatment group of infants were ready for bottle feeds earlier,
had fewer tube feeds, gained more weight and were discharged
earlier. Field et al17 and Seghal et al36 obtained similar results.
Recent studies23 24 have described a non-nutritive programme
more precisely. The treatment group received a daily 15-minute
oral stimulation programme (stroking the peri- and intra-oral structures), for 10 days prior to oral feeding. This is
an

impressive result given the relatively undemanding treatment


programme. The first study,18 found that independent oral
feeding was attained, on average, 11 days sooner in the group
that received the intervention within a group of 32 infants. In
addition, the treatment group went home 5 days sooner. The
later study19 looked again at 32 infants but those who had a
gestational age of between 26 and 29 weeks. The oral motor
programme commenced 48 h post-cessation of continuous
positive airway pressure (CPAP). The intervention was carried
out by nurses or researchers 30 minutes before a tube feed.
Those infants who had received the intervention went on to full
oral feeds 7 days sooner than the control group. Later studies
also demonstrate positive outcomes, but researchers or therapists
have carried out the intervention, rather than the parents
themselves.37 38 The Boiron et al study37 examined 43 infants
aged 2934 weeks gestation. The oral motor programme as
used by Fucile et al18 19 was carried out, but there were additional
groups involving use of cheek and chin support, use of oral
stimulation and support, and use of the oral stimulation alone.
The group that received both oral support and oral stimulation
took the least amount of time 5.6 days to move onto full
oral feeding. There was no mention of breast feeding, or
encouraging parents to participate in the programme. The
Rocha et al study,38 which looked at 98 very low birth weight
premature infants, also had similar outcomes. Speech and
language therapists carried out this intervention, but this was
largely focusing on bottle fed infants with little focus on
developing parental skills in enhancing the infants feeding
potential. This seems to go against the principles of collaborative
working with parents and carers that healthcare professionals
continually attempt to achieve.

RELATING THE LITERATURE TO CLINICAL PRACTICE


Clinically, therapists and nurses are aware of developing
positive oral experiences to promote both interaction and to
encourage and maximise oral skills.39 40 Early oral motor
stimulation is encouraged to maintain and develop the sucking
reflex. Within this framework, early communication and
learning to respond to the infants attempts to interact are an
integral part of a therapists role. Authors such as Harris24 and
Wolf and Glass23 recommend perioral and intraoral touch
pressure and nipple and finger-sucking experiences before bottle- or breast feeding. Bazyk39 suggests that nonnutritive
interventions for premature infants who receive tube feeds are
justified and can accelerate the transition from tube-to oral
feeding by allowing the infant to practise using their oral motor
musculature.

LIMITATIONS OF THE STUDIES


Review of the literature reveals that despite considerable
variability in methodology as well as in outcomes being
measured, non-nutritive sucking clearly has benefits in promoting
an infants readiness to begin oral feeding. The rationale as
to when to implement non-nutritive sucking, that is, before a
tube feed, on initiation of a tube feed, or after a tube feed, is
wide ranging, with unclear links to feeding development. In
addition, the major studies quoted1820 22 3739 focus on researchers
and staff, not parents actually carrying out the procedure, with
a high level of bottle fed infants, rather than a mixture of the
expected breast- and bottle feeders. As has already been stated,
breast feeding and the development of an infants ability to do
this pre-discharge are regarded as highly important. None of the
studies have any longitudinal aspect to them in terms of any
longer-lasting benefits for the infants participating, or have
reflected on the early communication development.41 Finally,
none of the studies actually use infants with neurodisability,
and hence the more typical speech and language therapy
caseload infants.

REFLECTIONS ON A PILOT PROJECT

A pilot study involving 14 infants41 devised a parent-lead nonnutritive


sucking programme based on speech and language
therapy principles. These principles focused on parents understanding
of the rationale underpinning the intervention where
they actually carried out the non-nutritive intervention to
promote both positive communication opportunity and develop
productive oral motor skills. The aims were to ascertain if a
parent-lead non-nutritive sucking programme assisted infant
feeding development, enabled effective development of jaw and
tongue movement and had any influence with long-term
benefits when the infants were ready to wean.
The study took place within a developmental care environment.
This study specifically was exploring the rationales
underpinning a recommended therapy approach, that is, nonnutritive
sucking to promote successful transition to oral
feeding within a population of premature infants.
Participants were recruited from the neonatal unit of a
district general hospital based in the south of England. All
parents gave informed consent after reading information
prepared for them and after discussion with the speech and
language therapist and nursing staff. They were advised that
they could withdraw consent at anytime.
Fourteen infants participated: 11 boys and three girls. Infants
were included if they were born between 27 and 35 weeks and
weighed between 1000 and 2000 g at 32 weeks after which oral
feeding was introduced. They were required to have a minimum
Apgar score of 3 at 1 minute and 5 at 5 minutes. Infants with
chronic medical problems (cardiac difficulties, unresolved respiratory
problems requiring oxygen, renal sepsis, surgery, or medications
with central effects, intra-ventricular haemorrhages, and
general congenital or neurological anomalies) were excluded.
A matched-pairs design was used. Infants were matched for
gestational age and birth weight and a member of each pair was
randomly allocated to a treatment or control group. Infants
were assigned to groups using a stratified random sampling technique to ensure that the groups were similar in
mean
gestational age and birth weight. Selection to the intervention or
control group was carried out by a computer-generated random
number system. The groups were compared on the length of their
stay in hospital, the number of days taken to transfer to full oral
feeding and the change in NOMAS scores during the intervention
(table 1). Informal follow-up occurred at 8 months.

Procedure
Four training sessions were delivered to nursing and medical
staff to provide a background to the intervention rationale.
Parents in the treatment group were expected to provide
10 minutes of oral stimulation by gently stroking the bottom lip
with a finger or dummy, then moving intraorally to stimulate
the tongue in a gentle front to back movement until the finger/
dummy was prompting a non-nutritive suck pattern. This was
carried out during the first 10 minutes of a tube feed.
The NOMAS was used to assess oralmotor performance
during non-nutritive sucking before and after intervention. It
scores infants on the number of normal, disorganised or
dysfunctional patterns seen. Disorganised patterns are characterised
by arrhythmic jaw movements, difficulties coordinating
a suckswallowbreathe pattern and an inability to slow
down the sucking pace. Dysfunctional characteristics include an
excessively wide jaw excursion or minimal excursion, asymmetry
of the jaw and limited tongue movement, and either a
flaccid or retracted tongue. The assessment was conducted by
the researcher and a peer unaware of the group allocation of the
babies, both trained users of NOMAS.
Data were collected at a scheduled tube feed prior to
implementation of the first oral feed when the infant was
3233 weeks. Non-nutritive sucking patterns were observed for
a 10-minute period and evaluated in terms of the NOMAS

categories.
Infants in the control group still received the usual developmental
care approach from the unit, with a speech and language
therapist providing verbal support and discussion of oral
feeding. Developmental care seeks to benefit infants by
adapting the nursery environment, adapting the care of the
infant, through an infant-lead approach, and through close
collaboration with the family.13 Care is individual and adjusted
to fit an infants emerging skills and needs and the needs of the
family. When infants in the experimental group started to tube
feed, parents kept the dummy/finger in the infants mouth for
10 minutes using the method described earlier. All parents who
elected to have a dummy used the Smoothie pacifier. This was
carried out three times a day. The researcher met with parents
and nursing staff daily to evaluate progress. Informal follow-up
occurred once the infants were 8 months of age.

RESULTS
Table 2 gives the median and range for each group. The pairs
of children within the groups were compared using the
MannWhitney U test. These showed that the treated group
took fewer days to achieve oral feeding (a difference of 3 days,
U=11 (n=14), p=0.082 .0.05: not significant, but trend
apparent, fig 1), and spent fewer days in hospital (difference of
5 days, U=16 (n=14), p=0.277 .0.05: not significant, fig 2).
It is interesting to note that infants of a lower gestational age
benefited more directly from the programme.
Table 3 shows the change in the number of normal aspects of
sucking using the NOMAS both before introduction of oral
feeds, and once the infant is on full oral feeds. The change inNOMAS scores from before introducing oral feeds to
when the
infant was able to take full oral feeds without tube support in
the two groups was compared. Table 3 shows the means and
ranges of scores, and results of the MannWhitney U test.
Parents received an informal follow-up telephone call
8 months after discharge. Comments from the parents of
infants who had received the intervention remarked that
weaning had progressed well. In addition, some commented
that they had felt they were providing support for their baby
and enabling them to develop skills by carrying out the nonnutritive
sucking programme. A parent from the control group
commented that her son had had significant difficulties
weaning, and was finding it difficult to move away from
pureed textures. Informal follow-up at 8 months of age
indicated that weaning was more quickly established with the
treatment group. Parents were asked to reflect on the nonnutritive
sucking programme. Comments from the treatment
group included: I felt that the sucking programme was helpful
not just to BS, but to me also. I often felt so helpless looking
after him, but the programme made me feel I was doing
something to help my son. Interestingly, parents in the control
group mentioned some difficulties with establishing weaning: I
dread mealtimes and I get really frustrated. Already I am getting
angry with him. This information was an informal consideration,
and does require a much more rigorous approach and
evaluation within a wider-scale study.

SUMMARY
The results gained from this study where parents carried out the
intervention were comparable to studies described in the
rationale,6 22 with treatment group infants going home 5 days
sooner than the control group, and gaining full oral feeding
ability 3 days sooner. In addition, significant differences were
noted with oral motor function as measured by use of the
NOMAS33 between both groups. More importantly, this study
involved the parents and carers actually carrying out the
intervention, not researchers. The informal follow-up at
8 months did highlight some issues that would benefit from
further study. Within this pilot project, this was only a

superficial exploration, and therefore requires a more rigorous


study that attempts to evaluate some of these issues further. It
is interesting to explore further the weaning development of
infants within an intervention group, although there will need
to be a more structured analysis of how and when the infants
developed. In addition to this, there is clearly a highly beneficial
effect for infants born earlier, and this has influenced to some
extent the populations used in two of the more recent
studies.37 38 It is possible to speculate on neonatal feeding
development in relation to plasticity of the system with earlier
gestational ages, although this finding clearly requires much
greater analysis and exploration.
In summary, it appears that there are undoubted benefits as
indicated by the literature discussed of using non-nutritive
sucking with infants who are premature. In particular, nonnutritive
sucking is seen to have benefits in terms of successful
transition to oral feeding and quicker discharge home.
Interestingly, infants who are born earlier benefit more from
the procedure than those born later, and this would clearly
benefit from further study.
It is hard to consider if other variables with the developmental
care model such as the sensory and tactile feedback
associated with use of Kangaroo Care contribute to an infants
well-being and therefore readiness to progress and develop other
skills such as feeding. However, most of these studies do not
make a clear distinction between breast- and bottle feeders; this
is an issue that does require further careful consideration given
the high priority and encouragement that is actually given to
breast feeding within the UK. In addition, within neonatal units
there is an ethos of encouraging parents to participate in aspects
of their infants care; only one paper attempts to address this
issue.38 Long-term implications are largely absent in terms of
longer-term benefits, although one paper tentatively explores
this.38 Finally, none of the papers discussed actually reflect on
the typical population that nurses and therapists would usually
implement a non-nutritive sucking programme with, that is,
those with neurodisability. Further research needs to build on
the current literature base and address these issues more clearly
so that a cohesive strategy for an approach that has undoubted
benefits for a vulnerable population can have clinical application
for a wider group.
Competing interests: None declared.
Ethics approval: Ethical approval was granted by the local Trust.
Patient consent: Parental consent obtained.

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